Is Cognitive Behaviour Therapy Effective for Changing Health Behaviours?

Commentary on Hobbis and Sutton

Journal of Health Psychology Copyright 2005 SAGE Publications London, Thousand Oaks and New Delhi, www.sagepublications.com Vol 10(1) 3336 DOI: 10.1177/1359105305048553

Abstract
Although Cognitive Behaviour Therapy (CBT) has successfully combined procedures based on behavioural and cognitive theories to reduce emotional problems, there is limited research into the efcacy of CBT in changing health behaviours. Of the studies cited by Hobbis and Sutton (this issue), only one measured health behaviours. In order to evaluate the effectiveness of behaviour change techniques, it is essential that the endpoints are behaviours, rather than health or emotional outcomes. There are both theoretical and circumstantial reasons for believing that CBT may be effective for changing health behaviours. Hobbis and Sutton have considered CBT as an addition to the Theory of Planned Behaviour-based interventions. It may be even more effective as an alternative.

SUSAN MICHIE
University College London, UK

SUSAN MICHIE

is a Reader in Clinical Health Psychology at University College London, UK. She is a chartered clinical and health psychologist, and President of the European Health Psychology Society.

COMPETING INTERESTS: ADDRESS.

None declared.

Keywords
behaviour, behaviour change, cognitive behaviour therapy, health behaviours, Theory of Planned Behaviour
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Correspondence should be directed to: S U S A N M I C H I E , Department of Clinical Health Psychology, University College London, Gower Street, London WC1E 6BT, UK. [email: s.michie@ucl.ac.uk]

JOURNAL OF HEALTH PSYCHOLOGY 10(1)

THIS TIMELY

article addresses the question of whether using Cognitive Behaviour Therapy (CBT) techniques can add to the efcacy of health behaviour change interventions based on the Theory of Planned Behaviour (TPB). Timely, because health psychologists are moving their focus of interest from predicting and explaining, to changing, behaviour. This raises the question of how to change behaviour. There is a recognition that persuasive communication, the basis of many health promotion and health psychology interventions, has only limited efcacy in changing behaviour. CBT, developed primarily to change emotional state, includes behaviour change techniques. The article by Hobbis and Sutton limits itself to considering interventions based on the TPB. This commentary addresses two questions: 1. Why interventions based on the TPB may not be effective for changing health behaviours. 2. Whether CBT may be more effective as an alternative, rather than as an add-on, to TPB interventions.

We do not have the evidence to test these explanations.

Is CBT effective for changing health behaviours?

CBT has developed from several theoretical and clinical strands. Techniques of behaviour change were developed in the rst half of the 20th century by psychologists such as Joseph Wolpe, John B. Watson and B. F. Skinner and applied within clinical psychology in the 1960s (see Kanfer and Goldstein, 1991; Kazdin, 2001). They were based on associative learning and the principles of classical and operant conditioning. An example of a simple technique that was applied to health behaviours in the 1960s (Leventhal, 1965, 1967) was to specify, in advance, where and when a behaviour would be carried out. This technique has been re-labelled more recently by some health psychologists as implementation intention formation. CBT, developed in the 1970s to reduce emotional problems, combines procedures based on behavioural and cognitive theories (e.g. Beck, 1963; Ellis, 1962), with good effect (Mahoney, 1974; Meichenbaum, 1977). Because changing health behaviours is not the primary task of clinical psychologists, there has been limited research into the efcacy of these techniques in the context of behaviour change and little evidence of the efcacy of CBT in changing health behaviours. An application of CBT is motivational interviewing (MI), developed by clinical psychologists to change addictive behaviours. MI is a client-centred, yet directive, method for enhancing motivation for change by exploring and resolving ambivalence to change. It uses a variety of cognitive and behavioural techniques, and has recently been applied to health problems (Resnicow et al., 2002). Hobbis and Sutton cite ve studies that demonstrate that CBT is applicable to health behaviours (Braet, Van-Winckel, & VanLeeuwen, 1997; Cowan, Pike, & Budzynski, 2001; Henry, Wilson, Bruce, Chisholm, & Rawling, 1997; Lewin et al., 2002; Liao, 2000). However, only one of these, Lewin et al. (2002) measured health behaviours (self-reported diet and daily walking). In order to evaluate the effectiveness of behaviour change techniques, it

Why are TPB interventions not effective?

Interventions based on the TPB are of limited efcacy in changing behaviour (Hardeman et al., 2002). There are several possible explanations. For example: 1. Targeted cognitions are conned to three types of belief: behavioural beliefs, normative beliefs and control beliefs. 2. Targeted cognitions are those most frequently reported as salient by a group, rather than those most salient to the individual. 3. Ineffective change techniques may be applied to cognitions (e.g. the most commonly used technique in TPB interventions, providing information, is known to be of low efficacy in changing behaviour). 4. Cognitive techniques are not used in conjunction with behavioural techniques, such as behavioural experiments, contingency control and action planning (see Bennett-Levy et al., 2004).
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MICHIE: IS CBT EFFECTIVE FOR CHANGING HEALTH BEHAVIOURS?

is essential that the endpoints are behaviours, rather than health or emotional outcomes (Michie & Abraham, 2004). Hobbis and Sutton consider the process, as well as the outcome of CBT. One statement in their article is puzzling: In applying CBT to health-related behaviours, it may not be necessary or desirable to elicit and modify core beliefs (p. 11). They distinguish between the cognitive techniques appropriate for mental health problems and those appropriate for physical health problems: Core belief work is usually considered appropriate for working with complex and enduring mental health problems. Thus, working at the level of core beliefs may not be necessary to promote change in health behaviour interventions (p. 11). The basis of the assumption that mental health problems are more complex and enduring than health behaviour problems is not clear. Core beliefs may be just as important for maintaining maladaptive behavioural responses as for maintaining maladaptive emotional responses, and both may be associated with mental health and with physical health problems. For example, if a person holds the core beliefs of I am worthless and things will never get better, he or she is unlikely to put the sustained effort needed into the business of behaviour change. Limiting cognitive interventions to the more accessible dysfunctional assumptions and negative automatic thoughts may limit the possibility of behaviour change if problematic core beliefs remain unchanged. It is analogous to running up an escalator that is going down. Effort may be put into changing dysfunctional assumptions (e.g. from thinking change is impossible to thinking that change is possible) and automatic thoughts (e.g. from I cant do this to I can do this). However, if the person continues to hold global beliefs, such as I am worthless and things will never get better, these will continually undermine progress made at the level of more consciously aware thoughts. There is insufcient evidence to answer the question as to whether CBT is effective for changing health behaviours. However, there are both theoretical and circumstantial reasons for believing that it may be. Hobbis and Sutton have considered CBT as an addition to TPBbased interventions. It may be even more

effective as an alternative. However, we lack evidence to evaluate either the process or outcome of TPB or CBT interventions to change health behaviours.

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